Transcript HIPAA and Beyond: The Emergence of a National Health HIPAA Summit

HIPAA and Beyond: The Emergence of a National Health
Information Technology Policy
HIPAA Summit
Baltimore, MD
Meryl Bloomrosen
Vice President, Programs
eHealth Initiative and its Foundation
September 14, 2004
Overview of Presentation
• Role of Healthcare Information Technology in
Improving Quality and Safety
• Recognition of Value by Administration,
Congress, Private Sector
• Emerging Interest in Community Collaboration
for Health Information Exchange and HIT
Adoption: Value; National Programs; Examples
• Barriers to Forward Movement and
Opportunities to Overcome Barriers
What Problems Are We Trying to Solve?
• Looming Healthcare Crisis
– Americans age 65+ will increase from 12% of
population in 1997 to 20% of population in 2030
– Rising healthcare costs - premiums increased
12.7% at the beginning of 2002
– Physicians leaving practice and nursing
shortage
– 44 million or 15.8% U.S. population uninsured
What Problems Are We Trying to Solve?
• Quality and Safety Challenges
– 44,000 to 98,000 deaths due to medical error
costing $37.6 billion annually
– 770,000 injured each year due to ADEs
– Adverse drug events in 5% to 18% of ambulatory
patients
– American adults on average receive only 54.9%
of recommended healthcare
What Problems Are We Trying to Solve?
• Fragmented Healthcare System
– Care is delivered by a variety of physicians,
hospitals and other providers - clinicians
providing care sometimes without knowing what
has been done previously and by whom
– Medicare beneficiaries see 1.3 – 13.8 unique
providers annually, on average 6.4/year
– Patient data unavailable in up to 81% of cases in
one clinic…other data shows 1/3 of time
– 18% of medical errors due to inadequate
availability of patient information
What Problems Are We Trying to Solve?
• “Un-wired” Healthcare System
• > 90% of the 30B U.S. health transactions each
year are conducted by phone, fax or mail
• % Revenues Invested in IT
11.10% - Financial Services
8.10% - Insurance
6.5% - Consumer Services
2.2% - Healthcare
• 1/3 hospitals have CPOE systems completely or
partially available - only 4.9% require their use.
• < 5% of U.S. physicians prescribe electronically
Value of Information Technology
• Improves Quality and Safety
• Drives Cost Savings
• Helps Patients Navigate the Healthcare
System
Why Information Technology Matters
It Improves Quality and Saves Lives
• National adoption of ACPOE (ambulatory
computerized physician order entry) would
prevent
– 2 million ADEs/year
– 190,000 ADE admissions/year
– 130,000 life-threatening ADEs/year
Center for Information Technology Leadership 2003
Why Information Technology Matters
It Improves Quality and Saves Lives
• Provider adoption of ACPOE would prevent
– 9 ADE/year
– 6 ADE visits/year and 4 ADE admissions/year
– 4 ADE admissions/5 years and 3 life-threatening
ADE/5 years
Center for Information Technology Leadership 2003
Why Information Technology Matters
It Saves Money
• Nationwide adoption of ACPOE would save $44
billion annually
• Nationwide adoption of standardized
healthcare information exchange among
healthcare IT systems would save $86.8
billion annually after full implementation
Center for Information Technology Leadership 2003, 2004
Why Information Technology Matters
It Saves Money
– Recent cost benefit analysis of EMR showed
use by primary care providers could result in
$86,000 in savings over five years. Benefits
include reduced drug spending, reductions in
radiology, and decreased billing errors.
– Kaiser Permanente study found that when
physicians used a computerized system, the
average time spent in the unit dropped by 4.9
days to 2.7, slashing costs by 25%
Value for Consumers
• Over 70% of consumers surveyed believe a PHR
will improve quality of care
• Consumers believed that having health information
online would:
• Clarify doctor instructions – 71%
• Prevent medical mistakes – 65%
• Change the way they manage their health –
60%
• Improve quality of care – 54%
* Source: Foundation for Accountability Survey for Connecting for Health
Value for Consumers
• More than half of consumers believe that their own
doctor and the health system as a whole is far more
“wired” than it actually is
• In response to question: “if you could keep your
medical records online, what would you do?”
• Email doctor – 75%
• Store immunization records – 69%
• Transfer information to specialist – 65%
• Look-up test results – 63%
• Track medication use – 62%
* Source: Foundation for Accountability Survey for Connecting for Health
Recognition of Value by Administration
• On President Bush’s Radar Screen
• Appointment of sub-Cabinet Level
Position – David J. Brailer, MD, PhD
• Strategic Plan Progress Report – 7/21
• Significant Increase in Focus by All
Federal Agencies
• Increased Funding in Administration’s
budget
President Bush’s State of the Union
“By computerizing health records, we
can avoid dangerous medical
mistakes, reduce costs and improve
care”
President George W. Bush - State of the
Union Address, January 20, 2004
President Bush’s April 26th Announcement
of 10-Year Plan for EHR
“Within the next ten years, electronic health
records will ensure that complete health
information is available for most Americans
at the time and place of care, no matter
where it originates.”
July 21, 2004 Framework for Strategic
Action – DHHS/ONCHIT
1. Inform Clinical Practice
– Incentivize EHR Adoption
– Reduce risk of EHR investment
– Promote EHR diffusion in rural and underserved
areas
2. Interconnect Clinicians
– Foster regional collaborations
– Develop a national health information network
– Coordinate federal health information systems
National HIT Coordinator – Strategic
Framework Goals
3. Personalize Care
– Encourage use of PHRs
– Enhance informed consumer choice
– Promote use of telehealth systems
4. Improve Population Health
– Unify public health surveillance architectures
– Streamline quality and health status
monitoring
– Accelerate research and dissemination of
evidence
Strategic Action Framework –
Key Actions that are Underway
• Establishment of HIT Leadership Panel with
recommendations by Fall 04
• Private sector certification of HIT products being
explored
• Funding of health information exchange
demonstrations – AHRQ, eHealth Initiative and
HRSA
• RFI release in summer for requirements for
private sector consortia that would form to plan,
develop and possibly operate a health
information network – not out yet…..
Strategic Action Framework –
Key Actions that are Underway
• Electronic prescribing as part of MMA
implementation by 2006
• CMS Medicare Beneficiary Portal
• FDA and NIH with CDISC have developed a
standard for representing observations made in
clinical trials
• As part of the Consolidated Health Informatics
Initiative Federal agencies have endorsed 20
sets of standards
• AHRQ $50 million HIT Program
NCVHS Recommendations on
Electronic Prescribing
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General standards compatibility
General standards versioning
Prescription messages
Coordination of prescription message
standards
• Formulary messages
• Eligibility and benefits messages
• Prior authorization messages
Recognition of Value by Congress
• Medicare Modernization Act
• NHII and National Health Information
Technology Legislation
• Patient Safety Improvement Act
IT Provisions in Medicare Modernization Act
• Electronic Prescription Program
• Establishes a real-time electronic prescribing
program for all who serve Medicare
beneficiaries with Part D benefits
• Requires following electronic information:
drug being prescribed, patient’s medication
history, drug interactions, dosage checking,
and therapeutic alternatives
• Requires uniform standards for e-prescribing
• Establishes a safe harbor from penalties
under the Medicare anti-kickback statute
IT Provisions in Medicare Modernization Act
• Grants to Physicians
• Authorizes Secretary to make grants to
physicians to defray costs of purchasing,
leasing, installing software and hardware;
making upgrades to enable eRx; and
providing education and training
• Requires 50% matching rate
• Authorizes appropriation of $50 million for
grants in FY 2007 and such sums as
necessary for fiscal years 2008 and 2009
IT Provisions in Medicare Modernization Act
• Payment Demonstrations
• Pay for performance demonstration program
with physicians encouraging adoption and
use of IT and evidence based outcomes
measures
• Four demonstration sites – carried over
three years
• HHS Secretary pays a per beneficiary
amount to each participating physician who
meets or exceeds specific performance
standards regarding clinical quality and
outcomes
IT Provisions in Medicare Modernization Act
• Chronic Care Improvement
• Phased-in development, testing,
implementation and evaluation by
randomized control trials of chronic care
improvement programs
• Proposals due August 6
• Required elements include monitoring and IT
tools
National Health Technology Legislation
• National Health Information Infrastructure
Act
– Sponsor: Rep. Nancy Johnson (R-CT)
– NHII Officer and NHII strategic plan including
public sector and private sector activities.
National Health Technology Legislation
• National Health Information Technology
Adoption Act (S. 2710)
– Sponsors: Senators Judd Gregg (R-NH), Bill
Frist (R-TN), Jeff Sessions (R-AL), Jim Bunning
(R-KY) introduced 7/21/04
– Establishes Director of Office of HIT - works with
public and private sectors to implement strategic
plan
– AHRQ and other federal agencies charged with
• Evaluating information relating to evidence of costs and
benefits of HIT
• Reviewing federal payment structures and differential for
healthcare providers that utilize HIT
National Health Technology Legislation
• National Health Information Technology
Adoption Act (S. 2710)
– Use private sector quality improvement
organizations to promote HIT adoption and
provide technical assistance
– Requires within two years, federal government
adoption of national data and communication
standards (voluntary for private sector)
– Limits federal HIT purchases to systems
compliant with standards within five years
National Health Technology Legislation
• National Health Information Technology
Adoption Act (S. 2710)
– Provides up to $50 million in loan fund
guarantees and $50 million for grants for local
health infrastructures
– Requires DHHS, VA and DoD to establish
uniform measures of quality
National Health Technology Legislation
• Patient Safety Legislation
– House passed Patient Safety Improvement Act
(H.R. 663) in March 2003
– Senate passed Patient Safety Improvement Act
(S. 720) on July 21, 2004
– Will be reconciled and conferenced in Fall 2004
– Both have IT provisions: development and
adoption of voluntary standards by DHHS; grant
funding in the House version of the bill
Recognition of Value by the Private Sector
• Ballot passed for HL7’s EHR functional model
• Number of pilot and actual incentive programs
launching – employers and health plans –
example is Bridges to Excellence
• Number of activities across all trade
associations designed to support effort
• Connecting for Health releases Preliminary
Roadmap for Electronic Connectivity on July 14
• eHealth Initiative Foundation launches
Connecting Communities for Better Health
Program – announces funding for nine
communities on July 21
Connecting for Health
• Catalyzing specific changes on national basis that
will rapidly clear the way for an interconnected,
electronic health information infrastructure
• Launched and funded by Markle Foundation with
support by the Robert Wood Johnson Foundation
• Leadership
– Chair: Carol Diamond and Executive Vice-Chairs: Dan
Garrett, John Lumpkin, Herb Pardes, MD
– Working Group Chairs: John Glaser, David Lansky, Clay
Shirky
– Technical Expert Panel: John Halamka, Mark Leavitt,
Marc Overhage, Wes Rishel, Paul Tang
– Executive Director: Janet Marchibroda
Connecting for Health Deliverables
• Preliminary Roadmap released July 14, 2004
• Series of recommendations for practical
strategies and specific actions to be taken over
the next one to three years
• Recommendations in Four Areas:
– Technical Architecture, Incremental Applications,
and Data Standards
– Accurately Linking Patient Information
– Organizational and Sustainability Models for
Community-Based Health Information Exchange
– Policies for Electronic Information Sharing
between Clinicians and Patients
Key Recommendations – July 2004
1. Creating a Technical Framework for Connectivity
– Creation of a non-proprietary network of
networks is essential to rapid acceleration of
electronic connectivity
– Need common framework of standards, policies
– Decentralized, federated, based on standards,
safeguards patient privacy, and built
incrementally without use of a National ID
– Test standards working together through
reference implementation and make widely
available
Key Recommendations – July 2004
2. Addressing Financial Barriers
– Financial incentives are needed – put a
number out there that would cause “tilt” - $3
to $6 per patient visit or $.50 to $1.00 per
member per month
– Create safe harbors to enable provision of
hardware, software, training by hospitals and
other providers
– Align incentives with standards-based
applications and connectivity
Key Recommendations – July 2004
3. Engaging the American Public
– Develop and employ a set of measures to
encourage the American public to become
partners in improving healthcare through IT
– Identify techniques, standards and policies to
be employed by all developers of personal
health records to ensure interoperability with
rest of healthcare system
eHealth Initiative Mission and Vision
Our Mission: Drive improvement in the quality, safety,
and efficiency of healthcare through information
and information technology
Our Vision: Consumers, providers and those
responsible for population health will have ready
access to timely, relevant, reliable and secure
health care information and services through an
electronic interoperable health information
infrastructure to promote better health and
healthcare
eHealth Initiative’s Members
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Health care information technology suppliers
Health systems and hospitals
Health plans
Employers and purchasers
Non-profit organizations and professional
societies
Pharmaceutical and medical device
manufacturers
Practicing clinician organizations
Public health organizations
Research and academic institutions
eHealth Initiative Focus for 2004
• Align incentives and promote public and private
sector investment in improving America’s
healthcare through IT and an electronic health
information infrastructure
• Develop the field to enable more widespread and
effective implementation of HIT and an electronic
health information infrastructure – particular focus
on community-based health exchanges and
clinicians
• Continue to drive adoption of standards to promote
an interoperable, interconnected healthcare
system
We’re Tackling Key Challenge Areas
• Upfront Financing Vehicles and Sustainable
Incentive Models
• Technical Aspects (Architecture, Applications,
Standards, Security) While Protecting Patient
Privacy
• Clinical Process and Organizational Change
• Organization, Governance and Legal Issues
• Engaging Patients and Consumers
Recap of eHI Accomplishments
1. Help put electronic connectivity and HIT “on the
map” in Administration and Congress
2. Launched $7 million Connecting Communities for
Better Health Program, a $7 million program
providing seed funding and support to multistakeholder collaboratives that are using IT
3. 450 community stakeholders from over 30 states
learned about HIT and health information exchange
at June Connecting Communities Learning Forum
4. Played key role in Connecting for Health
Recap of eHI Accomplishments
5. Convened 70 of the nation’s experts to develop
design, implementation, and incentives
recommendation for e-prescribing in ambulatory
care
6. Engaged employers/purchasers for over 60% of
insured Americans to increase awareness of the
need for electronic connectivity and HIT
7. Convened leaders from 16 nations to review the
challenges and strategies employed to create
electronic health information
infrastructure…AHRQ-funded to be released on
October 20, 2004
Recap of eHI Accomplishments
8. Developed recommendations related to Stark
9. Increased membership to over 150 members and
membership dues by 56% since 12/31
10. Diversified and increased revenue streams
11. Launched First Annual Health Information
Technology Summit to take place Oct 2004
Our Approach
Review,
Evaluate &
Develop
Models
Engage
Those Who
Can Effect
Change
Educate and
Advocate
For
Change
Provide
Resources
and Tools
Our Operating Model
AGGREGATE AND
DEVELOP
KNOWLEDGE IN
KEY ISSUE AREAS
VET WITH AND
DISSEMINATE
TO STAKEHOLDERS
PRIMARY
DISSEMINATION
VEHICLES
FINANCING
(Incentives, Funding)
CLINICIANS
ONLINE RESOURCE CENTER
LEGAL
(Data Use, Stark Issues)
HOSPITALS AND
OTHER PROVIDERS
VIDEO, WEB, PHONE
CONFERENCES
CLINICIAN ADOPTION AND
PROCESS CHANGE
HEALTHCARE IT
PHARMA AND DEVICE MFR
FACE TO FACE
CONFERENCES
PRIVACY
PUBLIC HEALTH
TARGETED BRIEFINGS
CLINICAL KNOWLEDGE
CHRONIC CARE
PAYERS
EMPLOYERS, PURCHASERS
PUBLICATIONS
TECHNICAL (STDS,
SECURITY, ARCHITECTURE)
PATIENTS, CONSUMERS
MEMBER ORGANIZATIONS
POLICY-MAKERS
Connecting Communities for Better Health
• Catalyzing activities at national, regional and local
level to create electronic interoperable health
information infrastructure
• $6.9 million program in cooperation with HRSA
…additional funding being secured
• Providing seed funding to community-based multistakeholder collaboratives that are mobilizing
information across organizations
Connecting Communities for Better Health
• Mobilizing pioneers and experts to develop
resources and tools to support health information
exchange: technical, financial, clinical,
organizational, legal
• Disseminating resources and tools and building a
dialogue across communities
– Through Community Learning Network and
Online Resource Center
– June 2004 Connecting Communities Learning
Forum
– Ongoing audio, video and web conferences
Connecting Communities for Better Health
• Creating and widely publicizing a pool of
“electronic health information exchange-ready”
communities to facilitate interest and public and
private sector investment
• Building national awareness regarding feasibility,
value, barriers, and strategies
Connecting Communities for Better Health
• Key partnering organizations
– Center for Information Technology Leadership –
Partners Healthcare System – Boston, MA
– Regenstrief Institute – Indiana Health
Information Exchange, IN
– Others in process of being finalized
Pioneers in Health Information Exchange*
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Bellingham, WA
Delaware
Florida
Indianapolis, IN
Los Angeles, CA
Maine
Maryland
Massachusetts
Michiana Health Information Network, IN
Michigan
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Pioneers in Health Information Exchange*
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New York
North Carolina
Ohio
Pennsylvania
Rhode Island
Santa Barbara, CA
Tennessee
Utah Health Information Network
Vermont
Washington, D.C.
*Sample
What Problems Are They Trying to Solve?
• Improving Healthcare Delivery at Point of
Care
• Reducing Costs – Achieving Efficiencies
• Biosurveillance/Public Health Initiatives
• Quality Improvement Initiatives
• Reaching out to Remote, Rural and
Underserved Areas
Common Issues and Challenges
• Upfront Funding and Sustainable Incentive Models
• Clinical Process and Work-flow Change (including
application of clinical knowledge)
• Organization, Governance and Legal Issues
• Technical (Architecture, Applications, Standards,
Security)
• Protecting Patient Privacy
• Engaging Patients and Consumers
Our Areas of Focus
• Upfront funding and incentives for
sustainability
• Clinician process and work-flow change,
application of clinical knowledge
• Electronic prescribing
• Organizational and legal issues
• Technical aspects to enable electronic
connectivity across organizations –
replicable models
Health Information Exchange Value
• Standardized, encoded, electronic HIE would:
– Save U.S. healthcare system $337B over 10 year
implementation period and $78B/year thereafter
– Net Benefits to Stakeholders
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Providers - $34B
Payers - $22B
Labs - $13B
Radiology Centers - $8B
Pharmacies = $1B
– Reduces admin burden of manual exchange
– Decreases unnecessary duplicative tests
Response to Request for Capabilities
• What We Asked For in our 2003 Request for
Capabilities Statements:
– Multi-stakeholder initiatives involving at least three
stakeholder groups
– Matched funding
– Use of standards and a clinical component
• What We Received:
– 134 responses representing 42 states and the
District of Columbia proposing collaborative health
information exchange projects across the country
Communities Being Funded
• Connecting Colorado (Denver, CO)
– Involves four healthcare delivery institutions
– Establishing a secure environment and necessary
legal framework for sharing clinical data
– Master patient index
– Interface engine for clinical data acquisition from four
data repositories
– Secure web server application to display integrated
clinical information
Communities Being Funded
• Indiana Health Information Exchange
(Indianapolis, IN)
– Involves hospitals, clinicians, and public health
– Building upon existing infrastructure for electronic
community health record developed by Regenstrief
– Common, secure electronic infrastructure that is
initially supporting clinical messaging
– Single IHIE electronic mailbox through which
clinicians can access clinical results for their patients
– Learnings shared through Connecting Communities
online resource center
Communities Being Funded
• MA-SHARE MedsInfo e-Prescribing Initiative
(Waltham, MA)
– Anchor project of the Massachusetts Health Data
Consortium’s MA-SHARE Program
– Involves health plans and hospital emergency rooms
– Enables clinicians to access prescription history for
emergency department patients
– Makes available electronic prescribing technology at
the point of service
Communities Being Funded
• MD/DC Collaborative for Healthcare Information
Technology (Baltimore/Washington Metro Area)
– Involves private physician practices, community
hospitals, three major academic systems
– Just getting off the ground…
– Will provide valuable insights on how to address the
challenges of health information exchange in a
complex, multi-jurisdictional, metropolitan setting that
combines federal, state and local entities
Communities Being Funded
• Santa Barbara County Care Data Exchange
(Santa Barbara, CA)
– Involves hospitals, physician group practices, public
health, labs, and clinics
– Manages peer to peer technology application whose
purpose is to allow community physicians and other
providers to securely share patient-specific data
without the necessity of a central data repository
– Learnings shared through Connecting Communities
online resource center
Communities Being Funded
• Taconic Health Information Network and
Community (Fishkill, NY)
– Involves 2,300 independent practice association,
hospitals, labs, health plans, pharmacies and
employers
– Clinical, insurance, administrative and demographic
information will be available through secure internet
infrastructure to support care delivery
– Ongoing support by MedAllies, which is providing
training and support to community clinicians and their
office staff
Communities Being Funded
• Tri-Cities TN-VA Care Data Exchange (Kingsport,
TN)
– Involves hospitals, VA medical center, medical groups,
public health, pharmacies, behavioral health care
providers, health plans and employers
– Providing foundation for health information exchange in
a multi-jurisdictional area
– Will support care delivery and chronic care
management
Communities Being Funded
• Whatcom County e-Prescribing Project
(Bellingham, WA)
– Involves Whatcom Health Information Network,
hospitals, medical groups, three specialty practices,
and pharmacies (hospital and retail-based)
– Will support electronic prescribing for those who have
and do not have an electronic health record
– Will test in four pilot sites product that provides
formulary information at point of prescription and
medication list
– Part of a broader initiative that is facilitating information
exchange between providers and patients
Communities Being Funded
• Wisconsin Health Information Exchange (National
Institute for Medical Informatics – Midwest)
(Milwaukee, WI)
– Involves public health agencies for nine counties,
hospitals, business coalition, medical society, and
hospital association
– Single easy-to-use portal for three existing networks:
network for emergency care, state public health
information network, and state immunization registry
Recap Communities’ Focus
• Strategically focused on critical areas that
need to be addressed to implement
health information exchange
– Replicable and sustainable technical
architecture models
– Alignment of incentive models
– Use of replicable data exchange standards
– Addressing ways to accurately link patient
data
– Multi-jurisdictional models
– Electronic prescribing issues
Barriers to Adoption
• Upfront Funding and Alignment of
Incentives (a Business Model)
• Interoperability Which Can be
Achieved through Standards
• Clinical Process and Work-flow
Changes Required
• Lack of Perceived “Value” by Many
• Lack of Awareness of Safety Benefits
• Not Yet a “Standard of Practice”
Opportunities to Enhance Value
• Improve usability: it’s all about speed of
operation, support of real workflow and ease of
learning and use
• Improve business case: align incentives
between those who bear the cost and those
who receive the benefit
• Improve connectivity to other systems…and
interoperability…using standards
• Make eRx an “incremental step” towards the
interoperable EHR and HIE – not a “dead-end”
Key Opportunities to Enhance Value
and Accelerate Adoption
• MMA implementation
• Implementation of DHHS Strategic Plan
• Emerging interest in incentives by public and
private payers
• Lessons from increasing number of demonstration
projects and implementations: AHRQ HIT, CMS,
eHI in cooperation with HRSA
• Emerging private sector coalitions, initiatives
• Lessons from U.S. pioneers and the U.K.
• Emerging legislation – will see increase in 2005
Key Imperatives
• Electronic prescribing standards in MMA
implementation should be well-thought through
and vetted considerably
• Financial incentives must be provided to
clinicians to support migration and they should
only support those applications that use
agreed-upon standards
• Exceptions to Stark and anti-kickback laws
need to be addressed…currently not sufficient
as proposed
Key Imperatives
• Demonstration projects and learning laboratories
should not be “one-offs”. They must test, evaluate
or provide learning to support migration of others
and their results should be widely communicated
• Reference implementations are needed to help us
understand how the standards work together and
to take them to the “next level” and their findings
and outputs placed in the public domain
• Investments in “dead-ends” should be discouraged
• Adoption of HIT applications should occur with
electronic connectivity in mind – a “network of
networks”
Key Imperatives
• Certification is needed by a trusted source that
represents all stakeholders in the system,
particularly users—including clinicians and
patients…the bar should be set at a baseline
functionality and migrate to higher levels over
time...
• Innovation is needed to provide support to
clinicians—particularly small to medium medical
practices—as they make the transition
Closing
• We are finally building momentum…the “stars and
planets are aligning”
• The focus has shifted from “whether we should” to
“how will we do this?”
• This work will create lasting and significant changes
in the U.S. healthcare system…how clinicians
practice…how hospitals operate….how healthcare
gets paid for…how patients manage their health
and navigate our healthcare system
Thank You
Meryl Bloomrosen
Vice President, Programs
eHealth Initiative and its Foundation
1500 K Street, N.W., Suite 900
Washington, D.C. 20039
202.624.3270
[email protected]